Creating safety for youth sexual health: Learning from experience

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Creating safety for youth sexual health: Learning from experience

Susana Guardado, MACD candidate

School of Public Administration

University of Victoria

Client:

Bobbi Turner, Executive Director

Island Sexual Health Society

Supervisor:

Thea Vakil, Associate Professor and

Associate Director

School of Public Administration,

University of Victoria

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Acknowledgments

This project would not have been possible without the support and contributions of several people.

I would like to thank Island Sexual Health for collaborating with me in this project. I am grateful to all the people who took the time to participate in the interviews and focus groups. In

particular, thank you to my client, Bobbi Turner and to Jennifer Gibson for being interested in this project, their support and for their commitment to providing youth friendly sexual health services.

I would also like to thank Dr. Thea Vakil for her guidance and support at every step of this project. Thank you as well to the 2014 MACD Cohort for being such a supportive group of inspiring individuals.

Finally, I would like to thank my family and friends for their love, support and patience throughout this educational journey. Thank you for encouraging me and believing in me.

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EXECUTIVE SUMMARY

Adolescence and young adulthood are crucial times in a person’s sexual development. In this time of cognitive, physical and emotional development youth often become sexually active and engage in exploration that may lead to risky behaviour with long term consequences. They are times when they are navigating societal expectations and pressures in regards to their sexuality and sexual wellbeing and when access to appropriate sexual health services and information can mitigate potential negative health outcomes. Island Sexual Health Society (ISH) currently plays a key role in providing this information and sexual health services for young people in the Greater Victoria area.

The objective of this project is to learn how youth-friendly services are defined and to provide ISH with informed strategies to increase the organization’s capacity to provide youth-friendly services. The research questions are as follows -

When youth access services at ISH:

⋅ What are their experiences of the different programs? ⋅ How do these experiences impact their sense of safety?

⋅ What do youth need in order to feel safe when accessing sexual health services at

ISH?

Background

ISH is a non-profit organization that provides clinical sexual health services, community education and outreach and product sales. The organization operates a central clinic and four satellite clinics including two in local high schools and one in Camosun College. ISH provides services to clients of all ages, however youth between the ages of 15 to 25 make up a majority of their client population. ISH has youth focused programs such as a sexual health education program in schools, a youth website and a youth advisory council. All services are confidential and free of charge.

Youth sexual health is a key health concern. Statistics indicate that youth have higher incidences of Sexually Transmitted Infections (STIs) than the rest of the population. Youth are also

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activity at a young age. STIs and high risk sexual behaviours can have serious negative and long term consequences for youth. These consequences are generally of a preventable nature that can be addressed through access to sexual health services and information.

Literature Review

The literature review focused on the themes of youth-friendly sexual health services models, risk factors and protective factors to youth sexual health, barriers youth face in accessing sexual health services and barriers providers face in delivering youth friendly services. The literature review included academic articles and professional publications published since 2000. Earlier literature focused on teenage pregnancy as the key indicator for sexual health.

The first segment of the review provided an overview of how sexual health services are

delivered, exploring different models of delivery as well as their strengths and weaknesses. The review then pointed to youth sexual health as a priority due to young people’s vulnerability to negative health outcomes and to the preventable nature of these outcomes. This section then explored the factors that place youth at risk and those that act as protective factors in their health and wellbeing. These factors were considered in relationship to the delivery of sexual health services. The literature identified youth in care, homeless youth, LGBTQ youth, Aboriginal youth and youth living with disabilities as particularly vulnerable to increased negative health consequences.

The literature review outlined barriers youth face in accessing services. The main barriers

identified were fear of not being treated with respect and fear that services were not confidential. The literature also considered the barriers faced by service providers. Key barriers included not having sufficient training on how to work with youth and lack of adequate funding to provide appropriate services for youth. The literature also provided an overview of characteristics of youth friendly services and recommendations on how organizations can best deliver accessible services for youth.

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Methodology

The project used a qualitative community based research approach. Three participant groups were identified and recruited using purposeful sampling. Group one included youth who are current or recent clients of ISH. Group two included staff and volunteers of ISH who interact with youth when they access ISH services and group three included community based youth workers who support youth in accessing ISH services. All participants self selected to participate in the project.

Focus groups incorporating community mapping strategies were used to gather information from group one participants. Focus groups are an appropriate research tool as youth generally feel more comfortable in a group of peers and more likely to engage in a group discussion than individual interviews. A total of 25 youth participated in three separate focus groups. Semi-structured interviews were utilised to gather information from participants in groups two and three. The interviews were approximately 45 minutes in length and included seven open-ended questions for staff and five open-ended questions for community youth workers. In total, 14 staff and volunteers and five community based youth workers participated in the interviews. A thematic analysis was used to reveal common themes within each group and across all three groups.

Findings and Discussion

The findings included participant views on characteristics of youth-friendly services, their thoughts on current ISH services and their recommendations for enhancing these services. The findings also included youth needs and realities and how these affect the approach to service delivery. Much of the findings from participants mirrored those in the literature review but included specific comments on ISH’s unique structure, design and approach.

Participants spoke about the special considerations that are necessary when providing services to youth. These include being aware of the high levels of anxiety and nervousness that youth experience when accessing sexual health services. A key finding was youth’s limited knowledge of their bodies and the medical system which impacts their ability to ask the right questions or to follow-up with treatments or testing. Participants described barriers youth face in accessing

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services including hours, transportation and cost of services or birth control. While ISH provides free services and birth control at reduced or no cost, the findings indicate that youth and youth workers are not necessarily aware of this. Cost, real or perceived, will prevent young people from accessing services.

Youth needs affect service delivery and program design. Participants talked about the urgent and immediate nature of youth sexual health needs which require flexibility in scheduling and often require additional staff time. Youth are also worried that services are not confidential and so confidentiality needs to be explicitly stated. Often youth clients have complex needs beyond what ISH is able to provide. Participants discussed the importance of a closer working

relationships with community youth workers and programs in order to provide further support to youth.

In regards to youth-friendly services, an overarching theme was the importance of ensuring youth have a positive experience in their interactions with staff at all points of contact. In general participants described youth and staff interactions at ISH as positive. Examples of negative experiences pointed to a lack of consistency throughout the different ISH service areas. A common theme that arose from both findings and literature was the need for staff to receive training on how to work with young people. Youth friendly services also include a flexible approach that caters to specific youth needs and work to remove barriers.

Recommendations

Nine short and medium-term recommendations and four long-term recommendations have been provided to ISH to assist them in increasing their capacity to be provide youth-friendly sexual health services.

Short and medium term recommendations:

1. Establish an explicit organizational culture that values and respects youth and prioritizes providing high quality services to young people. This can be achieved through staff training and revising HR policies.

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2. Further reduce barriers to youth access to services by providing choice of physician to see, addressing financial barriers and establishing youth-only clinic times.

3. Develop a close working relationship with community youth workers to address complex youth needs.

4. Examine ISH program design and structure to discern areas where relationship building with clients and continuity of care can be strengthened.

5. Increase the level of youth involvement and presence in ISH program design and evaluation through effective feedback tools and enhanced role of the Youth Advisory Council.

6. Develop strategies for reaching youth that identify as male.

7. Increase collaboration with other youth serving organizations to provide comprehensive services to youth. This includes direct updates to front-line youth workers, clear referral routes to other youth services, and knowledge sharing.

8. Increase the comfort and welcoming atmosphere of the clinic spaces. 9. Increase promotion of ISH services.

Long-term recommendations

1. Address the issue of 15-minute consultations by increasing nurse shifts and supplementing physician wages to increase their consultation times.

2. Expand hours and days of operations at existing satellite clinics.

3. Expand satellite clinics to create more accessible locations to more geographical areas of Greater Victoria.

4. Establish a youth-designated position at ISH.

Conclusion

This project grew out of ISH’s commitment to ensuring that youth have access to youth friendly sexual health services. that this project has captured how ISH currently offers youth-friendly servicers and provided the opportunity to hear from clients, staff and community youth workers how these services can be strengthened. The recommendations offer strategies for improvement based on the insights of research participants and are grounded in the literature. The project also highlights the importance of ensuring youth have access to appropriate, respectful and friendly sexual health services.

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sexually, develop a cognitive understanding of sexuality, and potentially become sexually active. It is a time of exploration that may lead to risky behaviour and potential negative physical, emotional and mental implications (Falk, Pederson, & Stanger, 2006, p. 14; Monasterio et al., 2007, pp. 302, 304; Poon et al., 2015, p. 5). Youth are navigating societal expectations and pressures, and seeking access to accurate information and health services. Island Sexual Health (ISH) is a non-profit organization located in Victoria, British Columbia. It offers a variety of sexual health services to the Greater Victoria region. ISH aims to provide high quality health services through the provision of inclusive services and resources, empowering individuals to make their own choices, and celebrating sexual diversity (Island Sexual Health, n.d.-a, para. 3). While ISH provides services to all ages, youth are a large portion of the clients they serve (B. Turner, personal communication, Aug. 20, 2015). This project aims to provide ISH with recommendations for increasing its capacity for providing accessible sexual health services to youth.

Definitions

This project follows the definition of sexual health presented by the World Health Organization as:

“A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships…” (World Health Organization [WHO], n.d. para 8)

The WHO further states that respect of sexual rights are a part of sexual health. These include access to the highest attainable sexual health services as well as the right to seek out information on sexual health (WHO, n.d., para 9). Sexual health services can refer to both preventative and intervention strategies. Services may include disease prevention, identification and cure,

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pregnancy prevention and care, information on sexual decision-making, gender and sexuality, and general services related to any aspect of sexual health and wellbeing.

For the purpose of this project youth is defined as people ages 15 to 24. This age range adheres to the definition of youth presented by the United Nations (United Nations Department of Economic and Social affairs, p.1, n.d.). The age range was selected in collaboration with the client who wanted to ensure the project looked at young people beyond the teenage years and into the early adulthood years. ISH runs three satellite clinics that target youth under the age of 25 in an effort to increase access for this age group.

Creating safety for youth sexual health is the main concept for this project. It was therefore important to explore this concept prior to the research. The concept was initially defined in collaboration with the client in setting the context. To set the stage for the research, safety was defined as the creation of a welcoming environment that is considerate of youth needs such as developmentally appropriate language, a client centered approach including the comfort of the physical clinic space and services that respect the confidentiality of clients.

The Problem

The client is interested and concerned to learn how youth define “youth-friendly and safe” services so that ISH may improve its service delivery to youth. Specifically, the project seeks to assess the experience of youth when they access services and offer strategies to remove barriers to access. ISH prides itself in providing the highest quality of care. However, the client is concerned that youth accessing ISH services do not always have a positive experience when accessing the range of services ISH offers and worries that this might deter youth from accessing important sexual health services and information (B. Turner, personal communication, May 2015). Of particular concern to ISH is identifying potential barriers for youth who already face multiple barriers due to marginalization and other risk factors. The client wishes to learn how to best deliver services that remove barriers to youth in accessing services.

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Research Question and Project Objectives

The project aims to answer the following questions:

When youth access services at ISH:

⋅ What are their experiences of the different programs? ⋅ How do these experiences impact their sense of safety?

⋅ What do youth need in order to feel safe when accessing sexual health services at ISH?

The objective of the project is to provide ISH with informed strategies that can assist the organization in preparing its staff and volunteers to provide services to youth.

Report Overview

The report is organized in eight chapters. After this introductory chapter, Chapter 2 provides background on the organization and the various services it offers. It also provides general statistics on youth sexual health and a discussion on what are considered sexual health services. The literature review is presented in Chapter 3. The review of the literature includes promising practices for youth sexual health services, identified barriers to access, and emerging youth needs in relation to sexual health. It also discusses the reasons why youth sexual health is a priority and the impact of youth not accessing health services. It also provides an overview of what are the characteristics of youth-friendly services. Chapter 4 provides information on the methodology used in this project. This chapter presents the methods used for selecting and interviewing participants. It provides an overview of the interviews, youth focus groups, and the community mapping tools used. Chapter 5 presents the findings of the research and is organized by each of the research groups: youth focus groups, ISH staff and volunteers, and community youth workers. Chapter 6 discusses the findings in relationship to the literature reviewed. Chapter 7 presents recommendations to ISH based on the analysis of the data gathered. Chapter 8 concludes the report.

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CHAPTER 2: BACKGROUND

This chapter provides information on Island Sexual Health’s (ISH) mission and vision, funding structures as they affect services, services provided and client statistics. The chapter also

provides information on youth sexual health statistics in Canada and BC. In particular, it looks at rates of Sexually Transmitted Infections (STIs), pregnancy and reported safe health practices among youth.

Project Client

ISH has been providing sexual health services to Southern Vancouver Island since 1986. The agency is a non-profit organization governed by a Board of Directors.

The organizational vision is:

“Island Sexual Health Society envisions a diverse community that celebrates healthy sexuality throughout life” (Island Sexual Health, n.d.-a, para. 2).

The organization’s mission as stated on its website is as follows:

“Island Sexual Health Society leads in delivering exemplary sexual health services to South Vancouver Island. Through the provision of clinical care and educations, we:

• empower individuals to make choices that enhance their sexual wellbeing;

• provide all inclusive services and resources that support sexual health;

• celebrate diversity of sexual expression.

Island Sexual Health Society defines sexual health as a state of physical, emotional, mental, and societal well-being related to sexuality”(Island Sexual Health, n.d.-a, para. 3)

ISH provides a variety of services and programs that include sexual health clinical services, community education services and outreach, product sales, and a volunteer program. The

organization is also a teaching facility for 2nd-year medical school residents and hosts practicum students from university programs. The different program areas can all be a point of access for youth.

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5 Clinical services

ISH provides clinical services at five separate locations in the Greater Victoria area. The main clinic is located on Quadra Street and is open six days a week. Four satellite clinics are located at the Landsdowne Campus of Camosun College, Royal Bay Secondary School, Belmont

Secondary School, and the Tsawout health building. The satellite clinics are open one day a week for approximately four hours. The Belmont School clinic ceased operations in September 2016 and was replaced by a general medical clinic operated by Island Health. The main clinic operates on a booked appointment schedule but can accommodate drop-in clients. The satellite clinics operate on a drop-in basis.

Clinic services are limited to sexual health concerns due to designated funding for this area and organizational mandate. Services include testing for Sexually Transmitted Infections (STIs) and pregnancy, treatment of STIs, pelvic, testicular and genital exams, and vaccinations. ISH also operates an Intra Uterine Device (IUD) insertion clinic once a week at the Quadra Street

location. Physicians provide prescriptions for birth control and medications for STIs. Clients can purchase these on site or from a pharmacy of the client’s choice. General Practitioners (GP) and nurses provide clinical services. ISH bills the Provincials Medical Services Plan for GP services under a fee-per-service structure. Island Health funds nurses at ISH. Clinical services also

provide follow-up and education to clients requiring information on birth control options or those who receive an STI diagnosis. Nurses and volunteer Birth Control Educators provide follow-up services. Nurses do not operate under the Medical Services Plan fee for service schedule, they are able to provide longer consultation times than the 15-minute GP consultation times. Clients under the age of 18are initially scheduled with a nurse who provides a longer initial consultation to discuss issues that bring them to the clinic.

Beyond the Talk: Community education program

The organization provides sexual health education to the community through workshops offered to schools and local organizations in the Greater Victoria community. The education program provides current and factual information, promoting positive sexuality and healthy decision-making. It also aims to prevent negative consequences of lack of information such as unintended pregnancies, STI’s and sexual exploitation (Island Sexual Health, n.d.-b, para. 1–3). In the 2014 – 2015school year, ISH delivered 496 workshops and reached 12,537 participants. The majority

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of the workshops were delivered to middle and high school students (Island Sexual Health, 2015, p. 12). The workshops provide information on sexual health and information on how to access ISH services and what to expect when attending an ISH clinic. They also provide information on the ISH website and texting program. An 8-hour curriculum that builds youths’ skills in talking to their peers on the topic of sexual health is available for school-based peer support or

leadership programs. Schools and community groups contact ISH to book workshops. There is an honorarium of $60 per workshop; a sliding scale or no fee is available to groups that are unable to pay the cost.

The Beyond the Talk program includes a youth advisory committee (YAC) made up of youth volunteers. Members of the youth committee also represent ISH at community events, raising awareness about ISH services and promoting positive sexuality. Previous committee activities include the creation of informational posters for community youth services, developing safer sex matchbook packages to be handed out at events, and an art exhibition focused on youth’s stories of puberty (Island Sexual Health, n.d.-e). A youth-focused website provides information on sexual health in a manner that is accessible to young people. It includes content on topics such as maturation, birth control and pregnancy, STIs, relationships, sexuality and gender. It also

provides links to additional resources and supports. Beyond the Talk also runs a texting line for youth. Youth can text any questions or concerns they have and receive answers from the

education team in a confidential manner. The program receives 2 to 10 texts daily (Island Sexual Health, 2015, p. 13).

Product sales

ISH sells birth control pills and products at lower costs than other major pharmacies. Youth between the ages of 14 to 17 who face financial barriers to accessing prescription birth control can receive it at no cost through a pharmaceutical compassionate program. Clients of the clinics at Belmont and Royal Bay schools receive free prescription birth control thanks to a grant received by ISH to cover these costs. A variety of condoms and lube are available for free at all the clinic spaces and as well as by the education team at workshops. As part of product sales, ISH runs Frisky Business, a social-enterprise located at the main clinic. Frisky Business sells a variety of sexual products in a space that is aimed to provide a comfortable and respectful

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experience for customers (Island Sexual Health, n.d.-c). Clients accessing prescription birth control at the main clinic, do so at the Frisky Business counter.

Volunteer program

ISH is not able to fully fund all the services required by its client population through MSP fees and grants (Island Sexual Health, 2015, p. 6). Its volunteer program allows it to provide a full range of client services. Volunteers play two key roles at ISH. Doctor’s Assistants (DA) assist in preparing the consultation rooms, guiding the client to the consultation room, providing support to the client when necessary during exams, and assisting doctors during consultations. They also assist in general clinic duties. The Birth Control Educators (BCE) provide individual education to clients on available birth control methods. They support clients in decision making and collaborate with physicians to answer further questions the client may have regarding

contraceptive methods (Island Sexual Health, n.d.-d). Youth can volunteer for these positions at the age of 18 once they are no longer in high school. Educators are the first point of contact for youth under the age of 18 who come to the main clinic for the first time.

Client statistics

In the 2015 to 2016 fiscal year ISH recorded the following statistics:

Table 1: Client Statistics Island Sexual Health

Total clients accessing ISH under age of 24

(Number indicate unique number of clients)

3,106

Youth accessing main clinic

(Total number of visits)

10,973 Youth accessing Camosun

Clinic (Number indicates total visits from Sept. to March)

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Youth accessing Royal Bay Clinic (Number indicates total visits from Sept. to June)

214

Youth accessing Belmont Clinic

(Number indicates total visits from Sept. to June)

400

Youth Sexual Health: Statistics

The following section provides information on current statistics on key indicators for youth health. Areas covered in this section include general safe sex practices and behaviours,

pregnancy rates, and STI rates. These are Canadian statistics, and where indicated BC specific statistics.

Sexual activity and safe sex practices

Studies indicate that behaviour such as multiple sexual partners, unprotected sex and sexual activity at a younger age can increase youths’ exposure and risk of negative sexual health incidences (Rotermann, 2012, p. 1). Youth who engage in safer sexual behaviour report fewer incidences of STIs and pregnancy (Poon et al., 2015, p. 24). Canadian statistics show that in 2010 66% of youth had had sexual intercourse at least once. Sexual activity increased with age, with 30% of 15 to 17-year-olds reporting sexual intercourse, and 86% of 20 to 24-year-olds reporting sexual intercourse (Rotermann, 2012, p. 1). Statistics also indicate that 8% of females and 10% of males report having sexual intercourse before the age of 15 (Rotermann, 2012, p. 1). The most common age of first intercourse reported for youth in BC was 15 (Poon et al., 2015, p. 10). The Canadian Youth, Sexual Health and HIV/AIDS study shows that approximately half of grade 7 students report some level of sexual activity including deep kissing and sexual touching below the waist (Boyce & Doherty-Poirier, 2006, p. 62). The same study indicates that more than half of grade 11 students have engaged in oral sex (p.62). In BC, 18% of students in high school reported engaging in oral sex and 19% reported having sexual intercourse (Poon et al., 2015, p. 10).

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Barrier methods such as condoms or dental dams are important in the prevention of STI’s and unintended pregnancies. Studies indicate that reported condom use among youth during their last sexual intercourse increased from 62% in 2003 to 68% in 2010 (Rotermann, 2012, pp. 1–2). Reasons given for not using condoms include not expecting sexual intercourse to occur, being under the influence of drugs and alcohol, being in a faithful relationship, and dislike of condoms (Boyce & Doherty-Poirier, 2006, p. 64). McCreary Centre’s report on youth sexual health indicates that in BC 70% of youth who engaged in sexual intercourse with someone of the opposite gender and 54% of youth who engaged in sexual intercourse with someone of the same gender used barrier methods (Poon et al., 2015, p. 16) . The report also indicates that youth are less likely to use these methods when engaging in oral sex. Only 20% of 15-year-olds and 13% of 17-year-olds reported using barrier methods last time they engaged in oral sex (Poon et al., 2015, p. 15). In general, statistics show a higher concern with pregnancy prevention than STI prevention (Boyce & Doherty-Poirier, 2006, p. 62).

Pregnancy

Youth pregnancy is seen as an indicator of young women’s sexual and reproductive health and well-being (Mckay, 2013, p. 163). Pregnancy rates among Canadian youth have been decreasing over the past decades. The Canadian Pediatric Society reported that in 2003 the rate of

pregnancies among women under the age of 20 was 27.1 per 1,000. This is comparison to 48.8 per 1,000 in 1994. From 2006 to 2010 the rates continued to decline in several provinces,

including BC, but increased in others (Leslie, 2006). The national rate in 2010 was 28.2 per 1000 while in BC the rate was 29.5 per 1000 (Mckay, 2013, pp. 164–165). It is estimated that in Canada abortions make up 52.1% of the teen pregnancy rate, however due to study limitations, this data is not available for BC (Mckay, 2013, p. 169). The BC Adolescent Health Survey found that 1% of youth reported having been involved in a pregnancy. Of youth that did not use any birth control method, 25% reported being involved in a pregnancy compared to 4% of youth who reported using some sort of pregnancy prevention method (Poon et al., 2015, p. 24).

Sexually Transmitted Infections

Statistics show that youth have a higher incidence of STIs than the general population (Falk, E., Pederson, A., & Stanger, 2006, p. 14; Public Health Agency of Canada, 2013, para. 1). STIs can have significant negative consequences for the health of a young person. They can cause

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complications in disease and impact reproductive and maternal health (National Expert Commission, 2011, p. 1).

In Canada incidences of chlamydia for youth have increased year after year since 1997 (Public Health Agency of Canada, 2013, para. 8). 80% of new cases in 2012 were among youth

(Challacombe, 2013, p. 2). In 2010, the rate of chlamydia infections for young women in Canada between the ages of 20 to 24, was seven times higher the national rate (Public Health Agency of Canada, 2013, para. 8). The rates in BC are similar to those in Canada with the second highest rates being recorded for females ages 15 to 19 (BC Centers for Disease Control, 2015, p. 5). It is estimated that the increase in rates can be attributed to improved testing techniques and increase in routine testing for young women (BC Centers for Disease Control, 2015, p. 5). Other

examples of STIs reveal a similar pattern. Rates for gonorrhea for the general population have increased in Canada and BC (BC Centers for Disease Control, 2015, p. 13). Young males ages 20 to 24 have the second highest rates of gonorrhea (BC Centers for Disease Control, 2015, pp. 13, 16). Youth have lower rates of syphilis than the general population in BC and while females have a lower syphilis rate than men, young women ages 20 to 24 have the highest rate of syphilis than women in other age groups (BC Centers for Disease Control, 2015, p. 27). Approximately one-quarter of new HIV diagnoses in Canada in 2013 were youth ages 15 to 29, with 79% of these being males. Of these, two-thirds were attributed to men who have sex with men (Challacombe, 2013, pp. 1–2). There is limited statistical information on other STIs such as herpes and HPV as incidences are not reported to health centers (Public Health Agency of Canada, 2013, para. 14).

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CHAPTER 3: LITERATURE REVIEW

The purpose of this literature review is to explore the broad topic of youth sexual health and the various subtopics that are relevant to the research question. The discussion begins by providing a brief description of the various models of sexual health service provision. The review will

consider the reasons why youth access to sexual health is important and the negative outcomes youth face if they do not access these services. It will further examine risk factors to sexual health as well as protective factors. This section will explore vulnerable youth populations including factors that put them at greater risk for negative health outcomes. The review will give an overview of barriers youth face in accessing sexual health services and barriers service providers face in delivering services to young people to access for youth and service providers. The literature review will include youth and service provider perceptions and how these play a role in barriers to access. Finally, the review will focus on characteristics of youth-friendly services and recommendations to create and enhance access to sexual health services.

The literature review was limited to material published after 2000 as teenage pregnancy tended to be the focus of earlier research and used as a key indicator of sexual health (Mckay, 2013, p. 163). The rate of teenage pregnancy in Canada dropped from 48.8 to 27.1 per thousand from 1994 to 2003 (Leslie, 2006, p. 1). Geographically, the search was limited to literature that focused on North America, Western Europe, and Australia because these societies share

sufficient similarities to allow for comparison to Canadian youth sexual health. Search keywords included terms that could refer to the relevant age group: youth, teenagers, and young adults. These terms combined with topics of sexual health such as sexual health services, reproductive health services, pregnancy prevention, sexually transmitted infection, and contraception. Other relevant search terms included access to service, barriers to service, youth-friendly services, and sexual health needs of youth.

Sexual Health Services

Sexual health services encompass a variety of delivery models and service provisions. Sexually transmitted infection (STI) prevention and treatment and preventing unintended pregnancies are the main concerns of sexual health services (Goesling, Colman, Trenholm, Terzian, & Moore, 2014, p. 500; Rogstad, Ahmed-Jushuf, & Robinson, 2002, p. 421). The literature identifies five

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main models of sexual health service delivery for youth: school based clinics, community based clinics, hospital based clinics, clinics within broader community services and outreach education services (Anderson & Lowen, 2010, p. 782; Tylee, Haller, Graham, Churchill & Sanci, 2007, p. 1567). Dehne and Riedner (2001) state that while school-based clinics are ideal for increased access and follow-up, these often leave out youth that are not attending school (p. 178). Kerr-roubicek and Elliott (2006) include an area-based youth health coordinator model, which comprises a key person to build collaboration between multiple stakeholders involved in the provision of youth health services (p. 53). Sexual health services are delivered through

specialized sexual health programs or through general health services (Rogstad et al., 2002, p. 421). Several studies highlight the use of technology such as websites and social media to deliver sexual health information and engage youth in accessing health services (Evers, Albury, Byron, & Crawford, 2013, p. 264; Heath, Flicker, & Nepveux, 2013, p. 5; Widman, Nesi, Choukas-Bradley, & Prinstein, 2014, pp. 613–614).

Youth Sexual Health as a Priority

Adolescence and young adulthood is a time of change, development and transition. Youth are developing their independence and their ability to make informed choices (Braeken, Otoo-Oyortey, & Serour, 2007, p. 1721; Cook, Erdman, & Dickens, 2007, p. 187). These

developmental changes can make youth more vulnerable to risk behaviour as their emotional and cognitive abilities develop (Tylee et al., 2007a, p. 1565). Cultural norms and peer influence impact young people’s sexual decision-making behaviours as well as their perception of risk and low sense of self-efficacy (Monasterio, Hwang & Shafer, 2007, pp. 305, 314). This is also a time when youth become increasingly concerned with confidentiality and autonomy (Tylee et al., 2007a, p. 1567). Anderson (2010) states that almost half of youth may be moderate to high risk due to their exploration of new behaviours combined with peer pressure and substance use (p. 780). Youth face higher risks in sexual health than adults and demonstrate a pattern of engaging in risky sexual behaviour (Cook et al., 2007, p. 188). These behaviours include multiple sexual partners, unprotected sex and sexual activity in their early teen years (Rotermann, 2012, p. 1). Youth are also a sector of the population that is less likely to access health services (Oberg, Hogan, Bertrand, & Juve, 2002, p. 320; Senderowitz, Hainsworth, & Solter, 2003, p. 1). In

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particular, McCreary Centre’s report on youth health found that sexually active youth were less likely than non-sexually active youth to seek medical care (Poon, Smith, Saewyc & McCreary, 2015, p. 27). A study of youth access to health services indicates that services need to reflect the developmental needs of youth if youth are to access them (Tylee et al., 2007a, p. 1565).A recurring theme is a connection between STI rates and the need for youth specific services. Youth have higher rates of STI’s than the general population (Falk, E., Pederson, A., & Stanger, 2006, p. 14; Goesling et al., 2014, p. 499; Hudson, 2012, p. 444). High rates of STI’s and pregnancy provides evidence for making accessible sexual health services for youth a priority (Cook et al., 2007, p. 183; Goldenberg, Shoveller, Koehoorn, & Ostry, 2008, p. 718; Robertson, 2013, p. 493). Widman, Neis, Choukas-Bradley, and Prinstein (2014) point to the need to understand the factors that contribute to sexual health risk among youth (p. 612).Youth’s poor use of birth control and STI prevention methods also point to the importance of removing barriers to access in to prevent negative sexual health consequences (Tripp & Viner, 2005, p. 592).

The negative outcomes of lack of access to sexual health services can be significant and long-term for young people (Bayley, 2003, p. 830; Tripp & Viner, 2005, p. 590). They include infertility, STI’s and unintended pregnancies (Hobcraft& Baker, 2006, p. 351; Maticka-tyndale, 2008, p. 89; Tripp & Viner, 2005, p. 590). Svoboda, Shaw, Barth and Bright (2012) point to the increased burden and risks that young mothers and their children face, such as poverty and increased health risks, as key reasons to ensure access to sexual health and pregnancy prevention services (p. 867). A decision to terminate unintended pregnancies can also have negative

consequences on a young person’s emotional and physical well-being (Cook et al., 2007, p. 183). The impact of STI’s is more significant for youth than for adults as their reproductive system is still developing and they are more susceptible to infection (Monasterio et al., 2007, p. 314). Incidences of disease and unintended pregnancies and their consequences can largely be prevented (Burke et al., 2014, p. 491; Goldenberg et al., 2008, p. 719; Kang et al., 2006, p. 49; Tylee et al., 2007a, p. 1565). Evidence shows that early detection and prevention services offered by youth-friendly sexual health services can reduce the impact of STI’s (Shoveller et al., 2009, p. 397; Tripp & Viner, 2005, p. 591). Research also shows that access to accurate and timely

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information can help youth make positive choices on their sexual health (Bayley, 2003, p. 831; Boyce & Doherty-Poirier, 2006, p. 59; Robertson, 2013, p. 494). Bayley (2003, p. 831) views adolescence as a window of opportunity in which information and services can significantly enhance and change a person’s behaviours. Likewise, Hobcraft and Baker (2006, p. 351) speak to the necessity of tailoring sexual health services to the needs of youth to decrease long-term negative effects.

Risk Factors for Youth Sexual Health

Several factors place youth at risk for poor sexual health and sexual decision-making. Some of these factors occur in the youth’s environment such as poverty, family instability, exposure to abuse and neglect (James, Montgomery, Leslie, & Jinjin Zhang, 2009, p. 990; Leslie, James, Monn, Kauten, & Aarons, 2011, p. 27; Svoboda, Shaw, Barth, & Bright, 2012, p. 867). Hudson (2012, p. 443) also identifies lack of access to medical care and health information as a risk factor for poor sexual health. Other risk factors include alcohol use, smoking, delinquency and drug use (Boyce & Doherty-Poirier, 2006, p. 60; Leslie et al., 2011, p. 27; Tripp & Viner, 2005, p. 590).Some of the risk factors identified in the literature are intrinsic. They include depression, suicidality, anxiety, high impulsivity, psychological immaturity (Leslie et al., 2011, p. 27; Svoboda et al., 2012, p. 867). DiClemente, Salazar, Crosby and Rosenthal (2005) include a young person’s lack of skills in negotiating sexual activities and sexual safety as another

contributing factor to higher risk (p. 827). These risk factors contribute to poor sexual health and to increased exposure to sexual violence, exploitation and coercion (Maticka-tyndale, 2008, p. 89).

There are specific populations of youth identified as vulnerable to higher risk for poor sexual health and higher consequences of poor health outcomes. These populations include youth in foster care, homeless youth, Aboriginal youth, youth living with disabilities and lesbian, gay, bisexual, transgendered and transsexual (LGBT) youth (Burke et al., 2014, pp. 491-494; Flicker et al., 2010, p. 134; Maticka-tyndale, 2008, p. 91; Oberg et al., 2002, pp. 329–333; Poon et al., 2015, p. 39). The literature reflected a main concern for the wellbeing of youth in care due to the high levels of abuse, neglect and violence that these young people have been exposed to and the impact of this trauma on their sexual behaviour (Hudson, 2012, p. 443; Leslie et al., 2011, p. 27;

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Love, McIntosh, Rosst, & Tertzakian, 2005, p. 7). In general, youth in government care have a lack of adult relationships, engage in sex at a younger age than their peers, report higher incidences of teen pregnancy and are less likely to seek out support (Love et al., 2005, p. 10; Robertson, 2013, p. 494). Ensign (2004) identifies homeless youth as being critically

underserved by the medical system and vulnerable to violence, abuse, and exploitation (p. 695). Oliver and Cheff (2012) support these findings and add that 95% of homeless youth were sexually active compared to 46% of the general youth population (p. 370). Aboriginal youth have poorer sexual health than the general youth population and experience high levels of psychological distress that expose them to poor sexual health outcomes (Banister & Begoray, 2006, p. 2006). Youth living with disabilities have compromised health issues, report higher involvement in risk-taking behaviour, have higher rates of mental health issues, and face limited access to information and sexual health services (McClelland et al., 2012, p. 809).Ginsburg et al.(2002) show that LGBT youth face social isolation, lack of support, report higher incidences of STI’s, are more likely to drop out of school and report suicidality (p.407). The study reveals that for youth, service provider characteristics such as friendliness and non-judgmental attitude is more important than any other factor. The McCreary Centre Society’s (2015) study on youth sexual health in BC indicates that youth in these groups who have intersecting risk factors are more likely to engage in higher risk taking and experience poorer health outcomes (p. 41). Existing services may overlook the specific needs of high-risk groups and authors suggest it is important to ensure that specialized services are available for these populations (Dehne & Riedner, 2012, p. 179,189; DiClemente, Salazar, Crosby, & Rosenthal, 2005, p. 826).

Protective Factors for Youth Sexual Health

Protective factors prevent and mitigate the effects of negative health outcomes and can lead to healthier sexual behavior (Poon et al., 2015, p. 42). There is general agreement within the literature that protective factors include positive connection to adults, connection to community, school and friends, hopes for the future, and healthy self-esteem (Anderson & Lowen, 2010, p. 783; DiClemente et al., 2005, p. 828; James et al., 2009, p. 991; Poon et al., 2015, p. 42). Ensign’s (2004,p. 703) study of homeless youth in Seattle, Washington, reports a positive relationship between youth having a positive connection with a health care provider and increased trust in adults. Oliver and Cheff also identify a positive connection as a protective

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factor. (2012, p. 375). Similarly, a positive connection to a service provider increases young women’s use of contraception methods (Poon et al., 2015, p. 45).

Barriers to Access – Youth

Youth face a variety of barriers in accessing sexual health services and information. Several studies identify similar barriers that prevent youth from receiving the care they need to access prevention or treatment for sexual health issues. These barriers include lack of confidentiality, embarrassment, cost of services or treatment, lack of transportation to the clinic, and clinic hours that do not cater to their schedules (Anderson & Lowen, 2010, p. 780; Bayley, 2003, p. 830; Goldenberg et al., 2008, p. 724; Kang et al., 2006, p. 49; Masaro, Johnson, Chabot, & Shoveller, 2012, p. 2; Monasterio et al., 2007, p. 309; Tanner et al., 2014, p. 200; Tylee et al., 2007a, p. 1566). In a review of studies on youth sexual health, Monasterio, Hwang and Shafer (2007, p. 309) name confidentiality as a key barrier for youth. The studies show that youth would forego care if they were not assured confidential services. Studies also show that even if the clinic had a confidentiality policy but it was not explicitly explained to the young person, this would prevent them from disclosing intimate and potentially important information (p. 309).

A study of BC’s northern communities indicates that youth will travel to other communities in an attempt to ensure their confidentiality (Shoveller et al., 2009, p. 398). A Nova Scotia based study identifies confidentiality as the main obstacle to accessing services (Langille, Murphy, Hughes, & Rigby, 2001, p. 221). Clinic hours are problematic to young people. If hours of operation are during school hours, they are unable to access the clinic unless they skip school or the clinic is at their school (Goldenberg et al., 2008, p. 722). The cost and access to contraceptives are the main reasons youth give for not using birth control or safe sex methods (Braeken et al., 2007, p. 173; Falk, E., Pederson, A., & Stanger, 2006, p. 15). Youth report not being aware of services, their location, or how to access them as another barrier to accessing sexual health services (Anderson & Lowen, 2010, p. 780; Goldenberg et al., 2008, p. 722; Kang et al., 2006, p. 49; Senderowitz et al., 2003, p. 2; Tylee et al., 2007a, p. 1565).

Several studies point to youth’s experiences with service providers or fear of judgement as a barrier to accessing services. Negative experiences with providers, be it the front-office staff,

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nurse or clinician can lead a youth deciding not to return to a clinic and prevent them from accessing future care (Buzi & Smith, 2014, p. 152). Hobcraft and Baker (2006, p. 353) explain that if youth are not greeted in a friendly manner with a smile, or if staff ask too many questions youth report feeling discouraged from seeking care. A negative experience can include a

provider’s attitude, as well as a lack of knowledge or expertise in sexual health (Goldenberg et al., 2008, p. 719). Youths fear that judgement by service providers prevents them from accessing health services or discussing particular health concerns (Bayley, 2003, p. 831; Tylee et al., 2007a, p. 1566). They are also afraid of the procedures providers will use (Tylee et al., 2007a, p. 1566).

Vulnerable youth populations report similar barriers as mainstream youth. They also report specific barriers that affect them directly. LGBT youth report fear of homophobia, preventing them from revealing their sexuality to physicians and as a result do not deal with concerns linked to their sexual behavior (Ginsburg et al., 2002, p. 407; Tanner et al., 2014, pp. 192–

193).Transgender youth report feeling segregated or excluded by heteronormative clinic practices such as intake forms that do not allow for them to select the gender they identify with or by physicians uneducated in the health needs of trans youth (Youth Gender Action Project, n.d., pp. 1–2). McClelland et al. (2012, p. 810) describe societal misconceptions about youth living with a disability as a major barrier to access. Providers view youth with disabilities as asexual or sexually inactive, and as not involved in risky sexual behaviour. Youth with

disabilities also face limited sexual information that considers their disability (Heath et al., 2013, pp. 12–13). Youth in foster care report receiving no necessary information on sexual health from their caregivers and state that it is important that providers bring up the topic of sexual health directly with them (Hudson, 2012, pp. 444–445; Love et al., 2005, p. 15).Unstable foster placements lead youth in care to miss a lot of school days and as a result miss sexual education provided through the schools (Robertson, 2013, p. 495). Exposure to sexual abuse can lead youth to be more fearful of sexual health procedures (Oberg et al., 2002, p. 333; Robertson, 2013, p. 495). Homeless youth face similar barriers to youth in care such as lack of access to information and the impact of exposure to abuse and exploitation (Ensign, 2004, p. 696; Oliver & Cheff, 2012, p. 371). Poor treatment by service providers is of particular concern to homeless youth as they experience maltreatment and marginalization is many aspects of their lives (Ensign, 2004, p.

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700; Oliver & Cheff, 2012, p. 371). Besides the listed obstacles, Aboriginal youth face the additional barrier of racism and accessing services that are incongruent with their cultural approach to health (Banister & Begoray, 2006, pp. 172, 169).

Barriers to Access – Service Providers

Service providers report a variety of barriers that prevent them from providing quality services to youth. Insufficient or inadequate training on how to work with youth and how to talk to youth about sexual matters leads to discomfort and hesitation in approaching the subject (Goldenberg et al., 2008, p. 725; Hansen, Barnett, Wong, Spencer, & Rekart, 2005, pp. 41, 46; Kang et al., 2006, p. 50; Love et al., 2005, p. 19; Langille et al., 2001, p. 219; Masaro et al., 2012, p. 2; Oberg et al., 2002, pp. 321, 323, 328; Oliver, van der Meulen, Larkin, & Flicker, 2013, p. e145). A review of physician practices shows that physicians will not always bring up the topic of sexual health with youth (Monasterio et al., 2007, p. 310). Many providers identify the fee for service billing structure as a barrier (Kang et al., 2006, p. 50; Masaro et al., 2012, p. 3-4; Oliver, et al., 2013, p. e145) as the time allowed per patient under this structure limits the time they are able to spend with youth (Hansen et al., 2005, p. 46). The Toronto Teen Survey found that the billing structure and the funding available for clinical sexual health services focus on treatment and disease prevention, and does not allow for time to provide extra support, teaching youth about negotiating sexual decision-making, or sexual pleasure (van der Meulen, Oliver, Flicker, & Travers, 2010, p. 187). Providers also speak of insufficient funding limiting their ability to provide adequate care for youth (Goldenberg et al., 2008, p. 719; Hobcraft & Baker, 2006, p. 351; van der Meulen et al., 2010, p. 185). In addition, sscarce resources often lead to providing services in unsuitable spaces (Masaro et al., 2012, p. 6).

Physicians often report viewing youth as children, with little knowledge or autonomy over own decisions thus do not engage youth as collaborators in their health care (Hobcraft & Baker, 2006, p. 352; Masaro et al., 2012, p. 8). A review of services indicates that often health care providers do not discuss confidentiality with youth and are unaware that this is a barrier for young people (Oberg et al., 2002, p. 323). Health care providers also express concern and frustration over youth not following up on treatment or testing (Goldenberg et al., 2008, p. 724; Masaro et al., 2012, p. 5). Some physicians identify the complex needs of youth patients as beyond what they

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are able to address, yet report limited knowledge of other available resources for youth and how to access them (Kang et al., 2006, p. 50).

Youth-friendly Services

Tanner et al. explain that the term youth-friendly is often used but rarely defined (2014, p. 199). They state that a youth-friendly service provides easily accessible services oriented to meeting the needs of youth. Their research found that youth-friendly services include those that allow youth to have more privacy, have staff trained in youth services, and provide comprehensive services to address the complex issues youth face (p. 199). The World Health Organization provides a framework for youth-friendly services (Tylee et al., 2007a, p. 1567) which includes: equitable points of access, accessible points of delivery, acceptable points of delivery,

appropriateness of services, and effectiveness of services (p. 1567). Main principles underlying youth-friendly services include addressing existing inequities and respecting youth’s right to access the highest possible standard of care (p. 1567). Youth-friendly services are those that have policies and characteristics meant to attract youth and offer a safe and respectful experience to them (Senderowitz et al., 2003, p. 3).

Several authors identify characteristics of a youth-friendly service. Characteristics include trained staff, respectful and non-judgmental treatment, privacy and confidentiality policies, and sufficient time for client and provider interaction. Facility qualities include a separate space for youth to wait, hours that consider youth schedules, convenient location and clinic space that is welcoming and comfortable. Program qualities include drop-in hours or appointments that are available in a short time, involving youth in the development and design of programming, information on available services, referral services, and diverse services to meet different needs. Providing information through alternate and innovative ways is also a youth friendly practice (Dehne & Riedner, 2012, p. 175; Ginsburg et al., 2002, pp. 410–411; Hobcraft & Baker, 2006, pp. 353–354; Hoffman, Freeman, & Swann, 2009, pp. 225–226; Monasterio et al., 2007, pp. 310–313; Rogstad et al., 2002, p. 421; Senderowitz, Hainsworth & Solter, 2003, p. 3). Ensign (2004, pp. 700–702) explains that youth value health care providers that demonstrate understanding of their needs, especially if they belong to a vulnerable group such as homeless

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youth. Youth want respectful treatment and to be a partner in their health care. Homeless youth spoke to the importance of providers understanding their defiant attitude as a survival

mechanism that will diminish as trust is built (Ensign, 2004, p. 705). Youth value a provider that is not rushed, seems comfortable with them and confident in the procedures they carry out (Ensign, 2004, p. 703; Hobcraft & Baker, 2006, p. 352). Youth also explain that health care providers are often their main source of trusted information (Ensign, 2004, p. 705; Hobcraft & Baker, 2006, p. 353). Continuity of care helps youth gain comfort in disclosing sexual health concerns and accessing services (Buzi & Smith, 2014, p. 152; Ensign, 2004, p. 702; Robertson, 2013, p. 497). Furthermore, Tanner et al. (2014, p. 203) state that positive interactions with staff is key to maintaining youth engaged in services and ensure that they will follow-up with

treatment.

Recommendations for Creating Youth-friendly Sexual Health Services

The literature recommends programs to attempt to meet criteria of youth-friendly service to ensure that sexual health services are accessible to young people. The recommendations focus on staff, structural and program design. Staff requires training on specific needs, challenges and issues that youth face (Burke et al., 2014, p. 492; Hoffman et al., 2009, p. 228; Kang et al., 2006, p. 57; Love et al., 2005, p. 25; Monasterio et al., 2007, p. 317; Oberg et al., 2002, p. 329; Oliver et al., 2013, p. e145; Senderowitz et al., 2003, p. 4; Travers et al., 2010, p. 195; Tylee et al., 2007a, p. 1571; Youth Gender Action Project, n.d., p. 5). Youth should receive a warm and welcoming experience at all points of access of the clinic (Hobcraft & Baker, 2006, p. 353; Oberg et al., 2002, p. 324; Tanner et al., 2014, p. 202). It is also important that the provider normalizes a young person’s concerns, is non-judgmental and provides accurate and clear information (Falk, E., Pederson, A., & Stanger, 2006, pp. 14–15; Ginsburg et al., 2002, p. 44). It is essential for service providers to explicitly state and explain their confidentiality policy and make it visible in the clinic space (Cook et al., 2007, p. 186; Hobcraft & Baker, 2006, p. 354; Monasterio et al., 2007, p. 310; Oberg et al., 2002, p. 323). Health care providers should take the initiative to address sexual health in a comfortable and timely fashion with young clients (Falk, E., Pederson, A., & Stanger, 2006, p. 15; Langille et al., 2001, p. 222). Where possible

consultation topics should go beyond physical health to discuss sexual consent, healthy relationships, and risk factors (Burke et al., 2014, p. 492).

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Authors indicate that it is vital that clinic location is convenient and easy to access (Oberg et al., 2002, p. 323; Shoveller et al., 2009, p. 400; van der Meulen et al., 2010, p. 189). Services should be widely promoted and visible so youth know what is available and how to access them

(Braeken et al., 2007, p. 173; Burke et al., 2014, p. 492; DiClemente et al., 2005, p. 831;

Senderowitz et al., 2003, p. 10; van der Meulen et al., 2010, p. 189). Some authors advocate for programs to increase privacy for youth such as the option for young clients to write down the reason for their visit rather than saying it out loud (Shoveller et al., 2009, p. 400) and to have a separate entrance or area for youth (Hobcraft & Baker, 2006, p. 355).

It is recommended that programs develop policies which allows for longer consultation times and relationship building with youth (Masaro et al., 2012, p. 7; Tanner et al., 2014, p. 204). To address the complex needs of youth, several studies endorse the provision comprehensive services or at the very least provide clear and supported referral pathways to other resources (Anderson & Lowen, 2010, p. 783; Oberg et al., 2002, pp. 334–335; Rogstad et al., 2002, p. 422). This includes increased collaboration between sexual health services and other support services for youth (Robertson, 2013, p. 496; Rogstad et al., 2002, p. 422). It is important for programs to develop resources and services that are inclusive and consider the specific needs of vulnerable youth populations (Dehne & Riedner, 2012, p. 179; Heath et al., 2013, p. 19;

McClelland et al., 2012, p. 818; Youth Gender Action Project, n.d., p. 5). Affordable, readily available, and one-dose treatment options increase effectiveness of treatment and reduce barriers due to lack of follow-up (DiClemente et al., 2005, p. 829).

The literature points to engaging youth in the evaluation, design, and development of services (Anderson & Lowen, 2010, p. 782; Braeken et al., 2007, p. 174; Hobcraft & Baker, 2006, p. 355; Love et al., 2005, p. 23; McClelland et al., 2012, p. 818; Rogstad et al., 2002, p. 422;

Senderowitz et al., 2003, p. 10; Tylee et al., 2007a, p. 1571). On-going evaluations will allow programs to assess their impact and level of youth friendliness of their services (Braeken et al., 2007, p. 174; Kang et al., 2006, p. 57; Love et al., 2005, p. 23; Youth Gender Action Project, n.d., p. 7). This includes creating methods and opportunities for youth to provide feedback (Ensign, 2004, p. 704).

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Humour is an important aspect to consider in the development of education and promotional material (Evers et al., 2013, p. 269). Secondly, programs should expand sexual health education to include pleasure, consent, sexual violence and communicating about sexual needs (Braeken et al., 2007, p. 174; Love et al., 2005, pp. 15–16; Oliver et al., 2013, p. e144; Poon et al., 2015, p. 56). Several authors recommend that programs explore models of peer support and education as a method for health promotion (Love et al., 2005, p. 24; Oliver et al., 2013, p. e145; van der Meulen et al., 2010, p. 189). Lastly, the literature recommends programs use technology as a tool to inform and engage with youth (Cecchino & Morgan, 2009, p. 32; Evers et al., 2013, p. 268).

Summary

The literature reviewed included program evaluation, review of research studies, and scans on the topic of youth and sexual health services. It highlights the gravity of negative sexual health outcomes for youth as a consideration for the importance of accessible services. It further

indicates that certain factors place youth at increased risk for risky sexual behaviour and negative sexual health outcomes. Some populations experience a higher burden of poor sexual health and have specific risk factors such as social isolation, a history of abuse, and lack of representation in the general youth population. Sexual health services play a role in increasing protective factors such as connection to adults and community.

Youth face a variety of barriers in accessing sexual health services. These include negative interactions with staff, inaccessible location and hours, and cost. While some barriers affect all youth, certain barriers such as heteronormative programs or assumptions of specific sexual behaviours affect vulnerable groups directly. Service providers also experience barriers to provide quality care to young people. These barriers include lack of training in working with young people, billing structures that limit consultation times and lack of resources to provide youth-friendly spaces. Characteristics of youth-friendly services and recommendations for programs to increase their capacity to provide youth-friendly services include qualities of staff and their approach to working with youth, staff training, and positive interactions with young people. Clinic space, location, and hours of operation are a way for programs to increase their

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level of youth-friendliness. Involving youth in the design and evaluation of services is an additional way to increase a program’s ability to provide services to young people.

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CHAPTER 4: METHODOLOGY

The project used a qualitative community based research (CBR) approach. CBR is a

collaborative methodology that brings together academic research and community partners to address a community identified need (Strand, Marullo, Cutforth, Stoecker, & Donohue, 2003, p. 5). CBR works to engage community partners throughout the research process and in doing so allows for capacity building and learning by everyone involved (Strand et al., 2003, p.6). The researcher worked closely with the project client to design the methodology, ensure that the methods proposed were in line with Island Sexual Health (ISH) values and to inform the process throughout the project. Strand et al., (2003, p. 7) point out that CBR has the potential to motivate social change and is based on a commitment to social justice. These values reflect the objectives of the project in exploring potential barriers youth may face in their experience at ISH and

providing strategies to remove them. The project used qualitative research methods to capture the experiences of youth, staff, volunteers and other youth service providers. Focus groups and semi-structured interviews provided a picture of the experiences and interactions of these groups with ISH services.

The researcher and project client identified three participant groups to give information from different perspectives. Youth who use ISH services to provide information as service users and offer insight on what they liked about the services as well as what would increase the youth-friendliness of ISH services. Staff and volunteers of ISH to talk about their experience as service providers and give information on what they need to better serve youth accessing ISH services. Youth workers to talk about their experience supporting youth to access ISH services. Youth workers can provide 3rd_{party information on youth’s experiences with services shared with the}

youth worker.

Sample

The project used purposive sampling to select research participants. Purposive sampling involves establishing criteria for participation to have information-rich samples (Patton, 2015, p. 264). The criteria for participation in this project were current or recent involvement with ISH services. This method provides a statistically representative sample that allows for

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generalization to a broader and larger group (Patton, 2015, p. 264). Participation was voluntary for all groups. Groups selected were

• Group one: Youth who have accessed ISH services at any of the clinic locations. • Group two: Staff and volunteers of ISH who meet youth accessing these services. • Group three: Community based youth workers who support youth in accessing ISH

services.

Recruitment

Recruitment for participants varied by sample groups. Posters advertising the focus groups were placed at the various clinic locations, ISH website and Facebook page. Small mini-posters were also available at the reception area for youth to take home. These mini-posters contained all the logistical information for the focus group as well as the researcher’s contact information. The researcher visited the Royal Bay and Belmont School clinics for two weeks prior to the focus group at each location and handed out mini-posters to young clients and explained the purpose of the group the importance of their voice to the project.

ISH staff and volunteers received an email from the Executive Director of ISH introducing the project. The researcher then sent an invitation to participate to all staff and volunteers. Those who decided to take part contacted the researcher who provided them with the consent form for their review. After feedback from an interviewee, the researcher forwarded participants the interview questions in advance. Three rounds of invitations to participate were sent over a period of three months. Fourteen staff and volunteers participated in interviews.

The project client identified key community organizations and youth workers that support youth in accessing ISH services. The researcher emailed them invitations to participate explaining that the client had identified them as potential key informants for this project. Interested youth workers contacted the researcher directly to set up interviews. Five community based workers participated in the project.

Creating safety for youth sexual health: Learning from experience